MEDICARE: KIRK D SCATTERGOOD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	36086	WI
2	207WX0107X	Retina Specialist (Ophthalmology) Physician	36086	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790702652
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRK D SCATTERGOOD MD

Provider Business Mailing Address
First Line	:	1035 KEPLER DR
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-8320
Country	:	US
Telephone Number	:	920-490-9046
Fax Number	:	920-405-8005

Provider Business Practice Location Address
First Line	:	30 N 18TH AVE STE 7
Second Line	:
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-3207
Country	:	US
Telephone Number	:	920-743-9532
Fax Number	:	920-743-9538

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	05/19/2026

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